527794
research-article2014
JADXXX10.1177/1087054714527794Journal of Attention DisordersFlannery et al.
Article
Does Emotion Dysregulation Mediate the Association Between Sluggish Cognitive Tempo and College Students’ Social Impairment?
Journal of Attention Disorders 1–11 © 2014 SAGE Publications Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1087054714527794 jad.sagepub.com
Andrew J. Flannery1, Stephen P. Becker1,2, and Aaron M. Luebbe1
Abstract Objective: Studies demonstrate an association between sluggish cognitive tempo (SCT) and social impairment, although no studies have tested possible mechanisms of this association. This study aimed to (a) examine SCT in relation to college students’ social functioning; (b) test if SCT is significantly associated with emotion dysregulation beyond depressive, anxious, and ADHD symptoms; and (c) test if emotion dysregulation mediates the association between SCT symptoms and social impairment. Method: College students (N = 158) completed measures of psychopathology symptoms, emotion dysregulation, and social functioning. Results: Participants with elevated SCT (12%) had higher ADHD, depressive, and anxious symptoms in addition to poorer emotion regulation and social adjustment than participants without elevated SCT. Above and beyond other psychopathologies, SCT was significantly associated with social impairment but not general interpersonal functioning. SCT was also associated with emotion dysregulation, even after accounting for the expectedly strong association between depression and emotion dysregulation. Further analyses supported emotion dysregulation as a mediator of the association between SCT and social impairment. Conclusion: These findings are important for theoretical models of SCT and underscore the need for additional, longitudinal research. (J. of Att. Dis. 2014; XX(X) 1-XX) Keywords ADHD, anxiety, depression, emotion regulation, SCT, sluggish cognitive tempo, social functioning There has recently been increased interest in the study of sluggish cognitive tempo (SCT) in children and adults (see Becker, Marshall, & McBurnett, 2014). Characterized by problems with daydreaming, staring, mental fogginess, confusion, hypoactivity, sluggishness, lethargy, and drowsiness, recent research has converged in demonstrating SCT symptoms to be an important construct in psychology and psychiatry (see Barkley, 2014; Becker, 2013; Becker, Marshall, & McBurnett, 2014). Although some research suggests that SCT may be important for identifying individuals who show problems in attention but few or no symptoms of hyperactivity (Carlson & Mann, 2002; Marshall, Evans, Eiraldi, Becker, & Power, 2014; cf. Willcutt et al., 2014), it has more recently been suggested that SCT represents a disorder that is distinct from, but highly related to, ADHD (see Barkley, 2014). In line with the latter hypothesis, more than a dozen studies conducted with children (Becker, Luebbe, Fite, Stoppelbein, & Greening, 2014; Burns, Servera, Bernad, Carrillo, & Cardo, 2013; Lee, Burns, Snell, & McBurnett, 2014; McBurnett et al., 2014; Willcutt et al., 2014) and adults (Barkley, 2012; Becker, Langberg, Luebbe, Dvorsky, & Flannery, 2013) have shown SCT to be statistically distinct from symptoms
of ADHD. As such, research has moved to examining external correlates of SCT, with a clear need for studies to also examine potential moderators and mediators of these associations.
SCT and Social Functioning Multiple studies conducted with children and adolescents demonstrate SCT symptoms also to be associated with social impairment (Bauermeister, Barkley, Bauermeister, Martínez, & McBurnett, 2012; Becker, 2014; Becker & Langberg, 2013; Becker, Luebbe, et al., 2014; Burns et al., 2013; Lee et al., 2014; Marshall et al., 2014). For example, recent research indicates that 75% of school-aged children with high levels of SCT are rated by their teachers as 1
Miami University, Oxford, OH, USA Cincinnati Children’s Hospital Medical Center, OH, USA
2
Corresponding Author: Stephen P. Becker, Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA. Email: [email protected]
Downloaded from jad.sagepub.com at GEORGIAN COURT UNIV on January 18, 2015
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Journal of Attention Disorders
functionally impaired in the peer domain, in contrast to only 8% of children with low levels of SCT (Becker, 2014). More specifically, Willcutt et al. (2014) found SCT symptoms to be significantly associated with social isolation and social withdrawal after controlling for symptoms of ADHD and other psychopathologies. However, despite the established link between SCT and youths’ social functioning, no studies have examined the association between SCT and social impairment in young adults.
SCT and Emotion Dysregulation Far fewer studies have examined SCT in relation to emotion, but extant research suggests that SCT is associated with problems in emotional functioning or, specifically, difficulties with emotion regulation. Emotion regulation is a multidimensional construct involving (a) awareness, understanding, and acceptance of emotions; (b) an ability to engage in goal-directed behaviors—and also refrain from impulsive behaviors—when experiencing negative emotions; (c) use of conditionally appropriate strategies to modulate the intensity and/or duration of emotional responses; and (d) an ability to recognize negative emotions as part of pursuing meaningful activities in life (Gratz & Gunderson, 2006; Gratz & Roemer, 2004). With these definitional considerations in mind, why might we hypothesize there to be an association between SCT and difficulties with emotion regulation? First, it is clear that SCT is significantly associated with internalizing symptoms of anxiety and depression (Bauermeister et al., 2012; Becker & Langberg, 2013; Becker, Langberg, et al., 2014; Becker, Luebbe, et al., 2014; Penny, Waschbusch, Klein, Corkum, & Eskes, 2009; Willcutt et al., 2014), and it is well established that internalizing symptoms are themselves linked to problems with experienced emotions as well as cognitive and behavioral regulation of negative emotions (Erk et al., 2010; Gross, 2003; Gross & Muñoz, 1995; Mennin, Heimberg, Turk, & Fresco, 2005; SaltersPedneault, Roemer, Tull, Rucker, & Mennin, 2006). As emerging work suggests that SCT may be more closely aligned with overarching internalizing versus externalizing psychopathology domains (Becker,et al., 2013), it is reasonable to expect SCT to likewise be associated with emotion regulation difficulties. Individuals with ADHD often experience emotion dysregulation as well. For example, Sjöwall, Roth, Lindqvist, and Thorell (2012) identified deficits in emotional functioning (e.g., parent-reported ability to calm the self when feeling anger, sadness, or fear; errors in recognition of emotions expressed on pictures of faces) as an important component for distinguishing between children diagnosed with ADHD and children without ADHD. Surman et al. (2012) found that 55% of adults with ADHD reported extreme deficiency of emotional self-regulation as measured by self-reported over-reactivity to negative emotions.
Furthermore, such deficits were rated as more severe than 95% of the control participants without ADHD. Given the strong association between SCT and ADHD (co-occurring among both children and adults in approximately 50% of cases of each; Barkley, 2012, 2013), it is reasonable to also expect SCT to be associated with problems in emotional functioning. Finally, there is some direct evidence suggestive of a link between SCT and emotion dysregulation. In a nationally representative sample of adults, Barkley (2012) found that SCT symptoms, ADHD-inattention symptoms, and ADHDhyperactive-impulsive symptoms each contributed unique variance in predicting adults’ self-ratings of deficits in the self-regulation of emotion (i.e., over-reacting emotionally to environmental cues). However, SCT explained far more variance in predicting emotion self-regulation deficits (44.5% of the variance) than either ADHD-inattention or ADHD-hyperactivity-impulsivity (1.4% and 7.7%, respectively). Similarly, Jiménez, Ballabriga, Martin, Arrufat, and Giacobo (2013) found SCT to be significantly associated with poorer emotional control in a sample of youth with ADHD, even after controlling for both ADHD-inattention and ADHD-hyperactivity-impulsivity. However, neither of these studies considered (or controlled for) internalizing symptoms, which, as described above, are themselves consistently and strongly associated with emotion dysregulation.
Emotion Dysregulation as a Mediator of the Association Between SCT and Social Impairment Emotion regulation supports positive social functioning and development (Cole, Michel, & Teti, 1994), and, in turn, emotion dysregulation is associated with social impairment in childhood (e.g., Denham et al., 2003; Eisenberg, Fabes, Guthrie, & Reiser, 2000). As emotion dysregulation is characterized by difficulties in perceiving, experiencing, and expressing emotions, it is not surprising that such difficulties would interfere with adaptive functions such as communication in close relationships and successful problem solving (Cole et al., 1994; Keenan, 2000). In comparison with research conducted with children and adolescents, fewer studies have examined emotion dysregulation (broadly construed) and social impairment in adulthood. Nonetheless, extant studies demonstrate an association between emotion regulation and college students’ social adjustment. For example, research conducted with college students demonstrates that greater ability in managing emotions (as assessed by a vignette measure in which participants identify the most adaptive way to regulate their feelings in a given context) is positively related to quality of social interactions with friends and individuals of the opposite sex (Lopes et al., 2004). Using the same methodology as the study just reviewed, emotion regulation abilities have
Downloaded from jad.sagepub.com at GEORGIAN COURT UNIV on January 18, 2015
3
Flannery et al. also been positively associated with both self-reports and peer nominations of interpersonal sensitivity and prosocial tendencies in college students (Lopes, Salovey, Beers, & Côté, 2005). Thus, as expected, emotion regulation is linked to college students’ overall social adjustment. Although previous research offers strong support for hypothesizing SCT to be related to social impairment, mechanisms of this association have yet to be uncovered. As SCT appears to be associated with emotion regulation (Barkley, 2012; Jiménez et al., 2013) and emotion regulation difficulties are also associated with social impairment (Cole et al., 1994; Denham et al., 2003; Eisenberg et al., 2000), it is plausible to hypothesize that the link between SCT and social impairment may be, at least in part, due to difficulties in the self-regulation of emotion. Willcutt et al. (2014) found SCT to be uniquely associated with increased social isolation and withdrawal in a large sample of children with and without ADHD. In discussing this finding, they speculated that “individuals with SCT may become overwhelmed by the rapid flow of complex information that must be processed continuously to successfully navigate social interactions, which may then lead to avoidance of social situations and subsequent isolation” (Willcutt et al., 2014, pp. 32-33). In essence, Willcutt and colleagues proposed that regulation— including emotion regulation—is a potential reason for the link between SCT and social impairment, and we sought to directly test this hypothesis in the present study.
courses (n = 132) and (b) a previous study of SCT and college student functioning that recruited students in an introductory psychology course during the prior semester (n = 26). Importantly, neither differences on demographic characteristics nor any study variable were found between these two groups (all ps > .05). In total, participants ranged in age from 18 to 23 years (M = 19.05, SD = 1.00) and approximately two thirds were female (64%, n = 101). The majority (84%) of participants self-identified as Caucasian; the remaining participants self-identified either as Asian/Asian American (7%), African American (5%), or Multiracial (3%). Most participants (n = 101) were in their first year of college; the remaining participants were in their second (n = 38), third (n = 13), fourth (n = 5), or sixth (n = 1) year of college.
Procedure This study was approved by the university Institutional Review Board (IRB). Interested participants were given individual time-slots, and after providing informed consent, completed the study measures on a computer in a university laboratory. Participants enrolled in an introductory psychology course at the time of their participation in the study received course credit for their participation; participants recruited from the previous semester’s study received US$10 in compensation for their time.
Measures
Study Hypotheses In sum, the aims of the present study were to (a) examine SCT in relation to college students’ social functioning as a way to replicate previous research almost exclusively conducted with children and adolescents; (b) test if SCT is significantly associated with deficits in emotion regulation over and above both ADHD and internalizing symptoms; and (c) test the hypothesis that emotion dysregulation mediates the association between SCT symptoms and social impairment. Given the literature reviewed above, we expected SCT to be uniquely related both to poorer social functioning and to greater difficulties with emotion regulation over and above other forms of pathology. We consider our third aim to be an exploratory first step given that the data we present are cross-sectional. As the first study to directly test this hypothesis, however, such analyses seemed warranted, and we expected emotion dysregulation to partially account for the relation of SCT to poorer social functioning.
Method Participants Participants were 158 undergraduate students enrolled at a public university in the Midwestern United States. Participants were recruited from two sources: (a) introductory psychology
SCT and ADHD symptoms. Symptoms of SCT and ADHD were assessed using the Barkley Adult ADHD Rating Scale–IV (BAARS-IV; Barkley, 2011a), an adult selfreport measure that includes 18 items corresponding to the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association [APA], 1994) symptoms of ADHD that have been updated in their wording to also reflect DSM-5 (5th ed.; APA, 2013) changes made to the ADHD symptom definitions. The BAARS-IV also includes nine symptoms of SCT (e.g., “I don’t seem to process information as quickly or as accurately as others,” “prone to daydreaming when I should be concentrating on something or working,” “spacey or ‘in a fog’”). Participants respond to each item using a 4-point scale (1 = not at all, 4 = very often). The four-factor structure of this measure consisting of separate SCT, inattention, hyperactivity, and impulsivity dimensions was established in a nationally representative sample of adults (Barkley, 2011a) and has been replicated in a large sample of college students (Becker, Langberg, et al., 2014). The subscales of the BAARS-IV demonstrate satisfactory internal consistency and test–retest reliability over a 2- to 3-week time period (Barkley, 2011a). Internal consistencies in the present study were as follows: SCT α = .88, ADHD-inattention α = .87, ADHD-hyperactivity α = .68, and ADHD-impulsivity α = .83.
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Journal of Attention Disorders
Depressive symptoms. The Center for Epidemiologic Studies Depression Scale–Short Form (CES-D-S; Radloff, 1977) was used as a continuous measure of depressive symptoms. The CES-D-S is a shortened 10-item self-report version of the 20-item CES-D. Participants use a 4-point scale (0 = rarely or none of the time [less than 1 day], 3 = most or all of the time [5-7 days]) to indicate how frequently they experienced each item (e.g., “I felt that I could not shake off the blues even with the help from my friends or family”) in the past week. The shortened form has been widely accepted as a comparable tool to the CES-D, as it correlates highly with the longer version and demonstrates comparable accuracy to the CES-D in classifying participants with depressive symptoms (Zhang et al., 2012). In the present study, CES-D-S α = .80. Anxious symptoms. The 7-item anxiety subscale of the Depression Anxiety Stress Scales–21 (DASS-21; Antony, Bieling, Cox, Enns, & Swinson, 1998; Lovibond & Lovibond, 1995) was used as a continuous measure of anxious symptoms. Like the CES-D-S, participants respond to each item (e.g., “I was aware of dryness in my mouth”) in reference to the past week using a 4-point scale (1 = did not apply to me at all, 4 = applied to me very much or most of the time). The DASS-21 and its subscales are widely accepted as being valid for use with college-aged participants and demonstrate high reliability (Antony et al., 1998; Sinclair et al., 2011). In the present study, anxiety α = .83. Social impairment. The Behavior Assessment System for Children, 2nd edition, Self-Report of Personality–College Version (BASC-2-SRP-CV; Reynolds & Kamphaus, 2004) and the Barkley Functional Impairment Scale (BFIS; Barkley, 2011b) were used to measure participants’ social functioning. Two measures of social functioning were used because the BASC-2-SRP-CV measures one’s own perception of general social competence, whereas the BFIS is specific to functional impairment. The combination allowed for an examination of general perceptions of interpersonal adjustment as well as impairment within the social domain. The BASC-2-SRP-CV is a multidimensional self-report survey of behavior and personality among college students. The nine-item Interpersonal Relations subscale was used in the present study. Items on this scale vary in format. First, participants responded to a single true/false item as either being generally true (coded as 2) or generally false (scored as 0) of themselves (i.e., “Other people don’t like me”). Participants then rated eight additional statements (e.g., “I feel that nobody likes me,” “people think that I am fun to be with”) on a 4-point scale (0 = never, 3 = always). After reverse-coding the negatively phrased items, a total score is computed as the sum of all items such that higher scores indicate better interpersonal functioning. Although a clinical T-score can be computed, the total raw score was used in the current study. The BASC-2-SRP-CV has shown to be
a consistent and reliable measure, and has shown good test– retest reliability over a 5-week period (Nowinski, Furlong, Rahban, & Smith, 2008). In the present study, α = .87 for the Interpersonal Relations subscale. The BFIS (Barkley, 2011b) is a 15-question self-report measure of functional impairment in 15 major domains of adult psychosocial functioning. Using a 10-point scale (0 = not at all, 9 = severe) as well as a “does not apply” option, participants rate how much difficulty they have functioning effectively in 15 major life activities (e.g., in your home life with your immediate family, in your work or occupation). The BFIS has previously demonstrated adequate validity, high internal consistency, and test–retest reliability over a 2- to 3-week interval (Barkley, 2011b). For the present study, a two-item composite of items pertaining to social interactions was computed such that higher scores indicated greater social impairment. Specifically, the two domains assessed included difficulty in functioning effectively: (a) in social interactions with strangers and acquaintances, and (b) in relationships with friends. A mean-item score was used for this composite (α = .85). One participant did not complete this measure and so analyses using this measure utilize a sample of 157 participants. Emotion dysregulation. The Difficulties in Emotion Regulation Scale (DERS; Gratz & Roemer, 2004) was used to measure participants’ emotion dysregulation. The DERS is a 41-item multidimensional scale that consists of six subscales measuring difficulties in one’s awareness and understanding of emotions, acceptance of emotions, and the ability to engage in goal-directed behavior (and refrain from impulsive behavior) when experiencing negative emotions. Respondents rate each item on a 5-point scale (1 = almost never; 5 = almost always), with items coded so that higher scores indicate greater difficulties in emotion regulation. The DERS is a widely accepted scale and has shown high internal consistency and good test–retest reliability over a period ranging from 4 to 8 weeks (Gratz & Roemer, 2004). Given high correlations among subscales, and little theoretical work to suggest differential relations between constructs of interest and specific subscales on the DERS, the total DERS score (α = .94) was used for analyses.
Results Preliminary Analyses Examining Participants With High SCT For purposes of describing the sample, we examined the percentage of participants meeting Barkley’s (2012) two criteria for having elevated SCT: (a) endorsing ≥5 symptoms of SCT on the BAARS-IV (Barkley, 2011a) at clinically significant levels (i.e., a score of “3” or “4”) and (b) being impaired in at least one BFIS domain based on the nationally representative sample validating the BFIS
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Flannery et al. Table 1. Means, Standard Deviations, and Intercorrelations of Study Variables. Variables
1
2
3
1. Sex — .10 −.27** 2. Race — −.13 3. Age — 4. SCT 5. ADHD-inattention 6. ADHD-hyperactivity 7. ADHD-impulsivity 8. Anxiety 9. Depression 10. BASC interpersonal 11. BFIS social impair 12. Emotion dysregulation M — — 19.05 SD — — 1.00
4
5
6
7
−.02 −.04 .11 —
−.15 .04 .15 .77*** —
−.16 .08 .14 .42*** .51*** —
−.05 .01 .10 .22** .26** .49*** —
2.11 0.62
1.71 0.53
1.87 0.57
1.65 0.63
8 .004 .01 .08 .55*** .48*** .47*** .37*** —
1.47 0.50
9
10
11
12
−.01 −.07 .10 .58*** .56*** .36*** .21** .69*** —
.12 .11 −.20* −.34*** −.32*** −.20** −.08 −.33*** −.51*** —
−.11 −.06 .15 .53*** .47*** .31*** .24** .50*** .60*** −.56*** —
−.05 −.13 .13 .58*** .55*** .41*** .27** .55*** .66*** −.54*** .59*** — 2.22 0.63
1.17 0.52
19.37 4.64
1.62 1.94
Note. Age is calculated in years. For sex, male = 0, female = 1. For race, 0 = non-White, 1 = White. Note that higher scores on the BASC represent better interpersonal functioning, whereas higher scores on the BFIS represent poorer social functioning. N = 158 for all analyses with the exception of those that use the BFIS (N = 157). SCT = sluggish cognitive tempo; BASC interpersonal = Behavior Assessment System for Children–College Version—Interpersonal Relations subscale; BFIS = Barkley Functional Impairment Scale. *p < .05. **p < .01. ***p < .001.
(Barkley, 2011b). In the current sample (recall that the BFIS was completed by 157 participants), 36 participants (23%) met the SCT symptom level criterion and 50 participants (32%) met the impairment criterion. Nineteen participants (12%) met both criteria and were thus classified as having high SCT. Independent-samples t tests indicated that, after applying a Bonferonni correction for multiple comparisons (.05/7 = .007), high SCT participants had higher BAARS-IV inattention, BAARS-IV hyperactivity-impulsivity, CES-D depression, DASS-21 anxiety, DERS emotion dysregulation, and BFIS social impairment scores, as well as lower BASC Interpersonal Relations scores, than participants without elevated SCT (all ps ≤ .001).
was significantly associated with poorer social functioning as measured by both the BASC Interpersonal Relations and the BFIS Social Impairment variables, with the exception that anxious symptoms were not significantly correlated with the BASC Interpersonal Relations domain. Likewise, each of the psychopathology dimensions was significantly positively associated with difficulties in emotion regulation, ranging from a correlation of .27 for the correlation between ADHD-impulsivity and emotion dysregulation to .66 for the correlation between depressive symptoms and emotion dysregulation. SCT, ADHDinattention, and anxiety were also strongly associated with emotion dysregulation (rs = .55-.58, all ps = .001).
Correlation Analyses
Regression Analyses
For all study variables, the absolute values of skewness and kurtosis were below 2.0. Variable means, standard deviations, and intercorrelations are displayed in Table 1. Correlations were examined to determine which independent variables (i.e., SCT, ADHD-inattentive, ADHDhyperactivity, ADHD-impulsivity, anxiety, and depression) and demographic variables (i.e., sex, age, and race) were associated with the dependent variables of interest (i.e., social functioning, difficulties in emotion regulation) and thus retained for inclusion in the regression analyses. As displayed in Table 1, age was significantly negatively correlated with BASC Interpersonal Relations (r = −.20, p = .01) and so was included as a covariate in all subsequent models. In addition, each of the psychopathology dimensions (i.e., SCT, ADHD-inattention, ADHDhyperactivity, ADHD-impulsivity, anxiety, and depression)
Next, hierarchical regression analyses were conducted to examine whether SCT symptoms were associated with difficulties in social functioning and emotion regulation after controlling for ADHD, anxious, and depressive symptoms. Across all regression analyses, no variance inflation factor (VIF) values were above 3 (values >10 are typically considered problematic) and no tolerance values were below .30 (values
research-article2014
JADXXX10.1177/1087054714527794Journal of Attention DisordersFlannery et al.
Article
Does Emotion Dysregulation Mediate the Association Between Sluggish Cognitive Tempo and College Students’ Social Impairment?
Journal of Attention Disorders 1–11 © 2014 SAGE Publications Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1087054714527794 jad.sagepub.com
Andrew J. Flannery1, Stephen P. Becker1,2, and Aaron M. Luebbe1
Abstract Objective: Studies demonstrate an association between sluggish cognitive tempo (SCT) and social impairment, although no studies have tested possible mechanisms of this association. This study aimed to (a) examine SCT in relation to college students’ social functioning; (b) test if SCT is significantly associated with emotion dysregulation beyond depressive, anxious, and ADHD symptoms; and (c) test if emotion dysregulation mediates the association between SCT symptoms and social impairment. Method: College students (N = 158) completed measures of psychopathology symptoms, emotion dysregulation, and social functioning. Results: Participants with elevated SCT (12%) had higher ADHD, depressive, and anxious symptoms in addition to poorer emotion regulation and social adjustment than participants without elevated SCT. Above and beyond other psychopathologies, SCT was significantly associated with social impairment but not general interpersonal functioning. SCT was also associated with emotion dysregulation, even after accounting for the expectedly strong association between depression and emotion dysregulation. Further analyses supported emotion dysregulation as a mediator of the association between SCT and social impairment. Conclusion: These findings are important for theoretical models of SCT and underscore the need for additional, longitudinal research. (J. of Att. Dis. 2014; XX(X) 1-XX) Keywords ADHD, anxiety, depression, emotion regulation, SCT, sluggish cognitive tempo, social functioning There has recently been increased interest in the study of sluggish cognitive tempo (SCT) in children and adults (see Becker, Marshall, & McBurnett, 2014). Characterized by problems with daydreaming, staring, mental fogginess, confusion, hypoactivity, sluggishness, lethargy, and drowsiness, recent research has converged in demonstrating SCT symptoms to be an important construct in psychology and psychiatry (see Barkley, 2014; Becker, 2013; Becker, Marshall, & McBurnett, 2014). Although some research suggests that SCT may be important for identifying individuals who show problems in attention but few or no symptoms of hyperactivity (Carlson & Mann, 2002; Marshall, Evans, Eiraldi, Becker, & Power, 2014; cf. Willcutt et al., 2014), it has more recently been suggested that SCT represents a disorder that is distinct from, but highly related to, ADHD (see Barkley, 2014). In line with the latter hypothesis, more than a dozen studies conducted with children (Becker, Luebbe, Fite, Stoppelbein, & Greening, 2014; Burns, Servera, Bernad, Carrillo, & Cardo, 2013; Lee, Burns, Snell, & McBurnett, 2014; McBurnett et al., 2014; Willcutt et al., 2014) and adults (Barkley, 2012; Becker, Langberg, Luebbe, Dvorsky, & Flannery, 2013) have shown SCT to be statistically distinct from symptoms
of ADHD. As such, research has moved to examining external correlates of SCT, with a clear need for studies to also examine potential moderators and mediators of these associations.
SCT and Social Functioning Multiple studies conducted with children and adolescents demonstrate SCT symptoms also to be associated with social impairment (Bauermeister, Barkley, Bauermeister, Martínez, & McBurnett, 2012; Becker, 2014; Becker & Langberg, 2013; Becker, Luebbe, et al., 2014; Burns et al., 2013; Lee et al., 2014; Marshall et al., 2014). For example, recent research indicates that 75% of school-aged children with high levels of SCT are rated by their teachers as 1
Miami University, Oxford, OH, USA Cincinnati Children’s Hospital Medical Center, OH, USA
2
Corresponding Author: Stephen P. Becker, Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA. Email: [email protected]
Downloaded from jad.sagepub.com at GEORGIAN COURT UNIV on January 18, 2015
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Journal of Attention Disorders
functionally impaired in the peer domain, in contrast to only 8% of children with low levels of SCT (Becker, 2014). More specifically, Willcutt et al. (2014) found SCT symptoms to be significantly associated with social isolation and social withdrawal after controlling for symptoms of ADHD and other psychopathologies. However, despite the established link between SCT and youths’ social functioning, no studies have examined the association between SCT and social impairment in young adults.
SCT and Emotion Dysregulation Far fewer studies have examined SCT in relation to emotion, but extant research suggests that SCT is associated with problems in emotional functioning or, specifically, difficulties with emotion regulation. Emotion regulation is a multidimensional construct involving (a) awareness, understanding, and acceptance of emotions; (b) an ability to engage in goal-directed behaviors—and also refrain from impulsive behaviors—when experiencing negative emotions; (c) use of conditionally appropriate strategies to modulate the intensity and/or duration of emotional responses; and (d) an ability to recognize negative emotions as part of pursuing meaningful activities in life (Gratz & Gunderson, 2006; Gratz & Roemer, 2004). With these definitional considerations in mind, why might we hypothesize there to be an association between SCT and difficulties with emotion regulation? First, it is clear that SCT is significantly associated with internalizing symptoms of anxiety and depression (Bauermeister et al., 2012; Becker & Langberg, 2013; Becker, Langberg, et al., 2014; Becker, Luebbe, et al., 2014; Penny, Waschbusch, Klein, Corkum, & Eskes, 2009; Willcutt et al., 2014), and it is well established that internalizing symptoms are themselves linked to problems with experienced emotions as well as cognitive and behavioral regulation of negative emotions (Erk et al., 2010; Gross, 2003; Gross & Muñoz, 1995; Mennin, Heimberg, Turk, & Fresco, 2005; SaltersPedneault, Roemer, Tull, Rucker, & Mennin, 2006). As emerging work suggests that SCT may be more closely aligned with overarching internalizing versus externalizing psychopathology domains (Becker,et al., 2013), it is reasonable to expect SCT to likewise be associated with emotion regulation difficulties. Individuals with ADHD often experience emotion dysregulation as well. For example, Sjöwall, Roth, Lindqvist, and Thorell (2012) identified deficits in emotional functioning (e.g., parent-reported ability to calm the self when feeling anger, sadness, or fear; errors in recognition of emotions expressed on pictures of faces) as an important component for distinguishing between children diagnosed with ADHD and children without ADHD. Surman et al. (2012) found that 55% of adults with ADHD reported extreme deficiency of emotional self-regulation as measured by self-reported over-reactivity to negative emotions.
Furthermore, such deficits were rated as more severe than 95% of the control participants without ADHD. Given the strong association between SCT and ADHD (co-occurring among both children and adults in approximately 50% of cases of each; Barkley, 2012, 2013), it is reasonable to also expect SCT to be associated with problems in emotional functioning. Finally, there is some direct evidence suggestive of a link between SCT and emotion dysregulation. In a nationally representative sample of adults, Barkley (2012) found that SCT symptoms, ADHD-inattention symptoms, and ADHDhyperactive-impulsive symptoms each contributed unique variance in predicting adults’ self-ratings of deficits in the self-regulation of emotion (i.e., over-reacting emotionally to environmental cues). However, SCT explained far more variance in predicting emotion self-regulation deficits (44.5% of the variance) than either ADHD-inattention or ADHD-hyperactivity-impulsivity (1.4% and 7.7%, respectively). Similarly, Jiménez, Ballabriga, Martin, Arrufat, and Giacobo (2013) found SCT to be significantly associated with poorer emotional control in a sample of youth with ADHD, even after controlling for both ADHD-inattention and ADHD-hyperactivity-impulsivity. However, neither of these studies considered (or controlled for) internalizing symptoms, which, as described above, are themselves consistently and strongly associated with emotion dysregulation.
Emotion Dysregulation as a Mediator of the Association Between SCT and Social Impairment Emotion regulation supports positive social functioning and development (Cole, Michel, & Teti, 1994), and, in turn, emotion dysregulation is associated with social impairment in childhood (e.g., Denham et al., 2003; Eisenberg, Fabes, Guthrie, & Reiser, 2000). As emotion dysregulation is characterized by difficulties in perceiving, experiencing, and expressing emotions, it is not surprising that such difficulties would interfere with adaptive functions such as communication in close relationships and successful problem solving (Cole et al., 1994; Keenan, 2000). In comparison with research conducted with children and adolescents, fewer studies have examined emotion dysregulation (broadly construed) and social impairment in adulthood. Nonetheless, extant studies demonstrate an association between emotion regulation and college students’ social adjustment. For example, research conducted with college students demonstrates that greater ability in managing emotions (as assessed by a vignette measure in which participants identify the most adaptive way to regulate their feelings in a given context) is positively related to quality of social interactions with friends and individuals of the opposite sex (Lopes et al., 2004). Using the same methodology as the study just reviewed, emotion regulation abilities have
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Flannery et al. also been positively associated with both self-reports and peer nominations of interpersonal sensitivity and prosocial tendencies in college students (Lopes, Salovey, Beers, & Côté, 2005). Thus, as expected, emotion regulation is linked to college students’ overall social adjustment. Although previous research offers strong support for hypothesizing SCT to be related to social impairment, mechanisms of this association have yet to be uncovered. As SCT appears to be associated with emotion regulation (Barkley, 2012; Jiménez et al., 2013) and emotion regulation difficulties are also associated with social impairment (Cole et al., 1994; Denham et al., 2003; Eisenberg et al., 2000), it is plausible to hypothesize that the link between SCT and social impairment may be, at least in part, due to difficulties in the self-regulation of emotion. Willcutt et al. (2014) found SCT to be uniquely associated with increased social isolation and withdrawal in a large sample of children with and without ADHD. In discussing this finding, they speculated that “individuals with SCT may become overwhelmed by the rapid flow of complex information that must be processed continuously to successfully navigate social interactions, which may then lead to avoidance of social situations and subsequent isolation” (Willcutt et al., 2014, pp. 32-33). In essence, Willcutt and colleagues proposed that regulation— including emotion regulation—is a potential reason for the link between SCT and social impairment, and we sought to directly test this hypothesis in the present study.
courses (n = 132) and (b) a previous study of SCT and college student functioning that recruited students in an introductory psychology course during the prior semester (n = 26). Importantly, neither differences on demographic characteristics nor any study variable were found between these two groups (all ps > .05). In total, participants ranged in age from 18 to 23 years (M = 19.05, SD = 1.00) and approximately two thirds were female (64%, n = 101). The majority (84%) of participants self-identified as Caucasian; the remaining participants self-identified either as Asian/Asian American (7%), African American (5%), or Multiracial (3%). Most participants (n = 101) were in their first year of college; the remaining participants were in their second (n = 38), third (n = 13), fourth (n = 5), or sixth (n = 1) year of college.
Procedure This study was approved by the university Institutional Review Board (IRB). Interested participants were given individual time-slots, and after providing informed consent, completed the study measures on a computer in a university laboratory. Participants enrolled in an introductory psychology course at the time of their participation in the study received course credit for their participation; participants recruited from the previous semester’s study received US$10 in compensation for their time.
Measures
Study Hypotheses In sum, the aims of the present study were to (a) examine SCT in relation to college students’ social functioning as a way to replicate previous research almost exclusively conducted with children and adolescents; (b) test if SCT is significantly associated with deficits in emotion regulation over and above both ADHD and internalizing symptoms; and (c) test the hypothesis that emotion dysregulation mediates the association between SCT symptoms and social impairment. Given the literature reviewed above, we expected SCT to be uniquely related both to poorer social functioning and to greater difficulties with emotion regulation over and above other forms of pathology. We consider our third aim to be an exploratory first step given that the data we present are cross-sectional. As the first study to directly test this hypothesis, however, such analyses seemed warranted, and we expected emotion dysregulation to partially account for the relation of SCT to poorer social functioning.
Method Participants Participants were 158 undergraduate students enrolled at a public university in the Midwestern United States. Participants were recruited from two sources: (a) introductory psychology
SCT and ADHD symptoms. Symptoms of SCT and ADHD were assessed using the Barkley Adult ADHD Rating Scale–IV (BAARS-IV; Barkley, 2011a), an adult selfreport measure that includes 18 items corresponding to the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association [APA], 1994) symptoms of ADHD that have been updated in their wording to also reflect DSM-5 (5th ed.; APA, 2013) changes made to the ADHD symptom definitions. The BAARS-IV also includes nine symptoms of SCT (e.g., “I don’t seem to process information as quickly or as accurately as others,” “prone to daydreaming when I should be concentrating on something or working,” “spacey or ‘in a fog’”). Participants respond to each item using a 4-point scale (1 = not at all, 4 = very often). The four-factor structure of this measure consisting of separate SCT, inattention, hyperactivity, and impulsivity dimensions was established in a nationally representative sample of adults (Barkley, 2011a) and has been replicated in a large sample of college students (Becker, Langberg, et al., 2014). The subscales of the BAARS-IV demonstrate satisfactory internal consistency and test–retest reliability over a 2- to 3-week time period (Barkley, 2011a). Internal consistencies in the present study were as follows: SCT α = .88, ADHD-inattention α = .87, ADHD-hyperactivity α = .68, and ADHD-impulsivity α = .83.
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Journal of Attention Disorders
Depressive symptoms. The Center for Epidemiologic Studies Depression Scale–Short Form (CES-D-S; Radloff, 1977) was used as a continuous measure of depressive symptoms. The CES-D-S is a shortened 10-item self-report version of the 20-item CES-D. Participants use a 4-point scale (0 = rarely or none of the time [less than 1 day], 3 = most or all of the time [5-7 days]) to indicate how frequently they experienced each item (e.g., “I felt that I could not shake off the blues even with the help from my friends or family”) in the past week. The shortened form has been widely accepted as a comparable tool to the CES-D, as it correlates highly with the longer version and demonstrates comparable accuracy to the CES-D in classifying participants with depressive symptoms (Zhang et al., 2012). In the present study, CES-D-S α = .80. Anxious symptoms. The 7-item anxiety subscale of the Depression Anxiety Stress Scales–21 (DASS-21; Antony, Bieling, Cox, Enns, & Swinson, 1998; Lovibond & Lovibond, 1995) was used as a continuous measure of anxious symptoms. Like the CES-D-S, participants respond to each item (e.g., “I was aware of dryness in my mouth”) in reference to the past week using a 4-point scale (1 = did not apply to me at all, 4 = applied to me very much or most of the time). The DASS-21 and its subscales are widely accepted as being valid for use with college-aged participants and demonstrate high reliability (Antony et al., 1998; Sinclair et al., 2011). In the present study, anxiety α = .83. Social impairment. The Behavior Assessment System for Children, 2nd edition, Self-Report of Personality–College Version (BASC-2-SRP-CV; Reynolds & Kamphaus, 2004) and the Barkley Functional Impairment Scale (BFIS; Barkley, 2011b) were used to measure participants’ social functioning. Two measures of social functioning were used because the BASC-2-SRP-CV measures one’s own perception of general social competence, whereas the BFIS is specific to functional impairment. The combination allowed for an examination of general perceptions of interpersonal adjustment as well as impairment within the social domain. The BASC-2-SRP-CV is a multidimensional self-report survey of behavior and personality among college students. The nine-item Interpersonal Relations subscale was used in the present study. Items on this scale vary in format. First, participants responded to a single true/false item as either being generally true (coded as 2) or generally false (scored as 0) of themselves (i.e., “Other people don’t like me”). Participants then rated eight additional statements (e.g., “I feel that nobody likes me,” “people think that I am fun to be with”) on a 4-point scale (0 = never, 3 = always). After reverse-coding the negatively phrased items, a total score is computed as the sum of all items such that higher scores indicate better interpersonal functioning. Although a clinical T-score can be computed, the total raw score was used in the current study. The BASC-2-SRP-CV has shown to be
a consistent and reliable measure, and has shown good test– retest reliability over a 5-week period (Nowinski, Furlong, Rahban, & Smith, 2008). In the present study, α = .87 for the Interpersonal Relations subscale. The BFIS (Barkley, 2011b) is a 15-question self-report measure of functional impairment in 15 major domains of adult psychosocial functioning. Using a 10-point scale (0 = not at all, 9 = severe) as well as a “does not apply” option, participants rate how much difficulty they have functioning effectively in 15 major life activities (e.g., in your home life with your immediate family, in your work or occupation). The BFIS has previously demonstrated adequate validity, high internal consistency, and test–retest reliability over a 2- to 3-week interval (Barkley, 2011b). For the present study, a two-item composite of items pertaining to social interactions was computed such that higher scores indicated greater social impairment. Specifically, the two domains assessed included difficulty in functioning effectively: (a) in social interactions with strangers and acquaintances, and (b) in relationships with friends. A mean-item score was used for this composite (α = .85). One participant did not complete this measure and so analyses using this measure utilize a sample of 157 participants. Emotion dysregulation. The Difficulties in Emotion Regulation Scale (DERS; Gratz & Roemer, 2004) was used to measure participants’ emotion dysregulation. The DERS is a 41-item multidimensional scale that consists of six subscales measuring difficulties in one’s awareness and understanding of emotions, acceptance of emotions, and the ability to engage in goal-directed behavior (and refrain from impulsive behavior) when experiencing negative emotions. Respondents rate each item on a 5-point scale (1 = almost never; 5 = almost always), with items coded so that higher scores indicate greater difficulties in emotion regulation. The DERS is a widely accepted scale and has shown high internal consistency and good test–retest reliability over a period ranging from 4 to 8 weeks (Gratz & Roemer, 2004). Given high correlations among subscales, and little theoretical work to suggest differential relations between constructs of interest and specific subscales on the DERS, the total DERS score (α = .94) was used for analyses.
Results Preliminary Analyses Examining Participants With High SCT For purposes of describing the sample, we examined the percentage of participants meeting Barkley’s (2012) two criteria for having elevated SCT: (a) endorsing ≥5 symptoms of SCT on the BAARS-IV (Barkley, 2011a) at clinically significant levels (i.e., a score of “3” or “4”) and (b) being impaired in at least one BFIS domain based on the nationally representative sample validating the BFIS
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Flannery et al. Table 1. Means, Standard Deviations, and Intercorrelations of Study Variables. Variables
1
2
3
1. Sex — .10 −.27** 2. Race — −.13 3. Age — 4. SCT 5. ADHD-inattention 6. ADHD-hyperactivity 7. ADHD-impulsivity 8. Anxiety 9. Depression 10. BASC interpersonal 11. BFIS social impair 12. Emotion dysregulation M — — 19.05 SD — — 1.00
4
5
6
7
−.02 −.04 .11 —
−.15 .04 .15 .77*** —
−.16 .08 .14 .42*** .51*** —
−.05 .01 .10 .22** .26** .49*** —
2.11 0.62
1.71 0.53
1.87 0.57
1.65 0.63
8 .004 .01 .08 .55*** .48*** .47*** .37*** —
1.47 0.50
9
10
11
12
−.01 −.07 .10 .58*** .56*** .36*** .21** .69*** —
.12 .11 −.20* −.34*** −.32*** −.20** −.08 −.33*** −.51*** —
−.11 −.06 .15 .53*** .47*** .31*** .24** .50*** .60*** −.56*** —
−.05 −.13 .13 .58*** .55*** .41*** .27** .55*** .66*** −.54*** .59*** — 2.22 0.63
1.17 0.52
19.37 4.64
1.62 1.94
Note. Age is calculated in years. For sex, male = 0, female = 1. For race, 0 = non-White, 1 = White. Note that higher scores on the BASC represent better interpersonal functioning, whereas higher scores on the BFIS represent poorer social functioning. N = 158 for all analyses with the exception of those that use the BFIS (N = 157). SCT = sluggish cognitive tempo; BASC interpersonal = Behavior Assessment System for Children–College Version—Interpersonal Relations subscale; BFIS = Barkley Functional Impairment Scale. *p < .05. **p < .01. ***p < .001.
(Barkley, 2011b). In the current sample (recall that the BFIS was completed by 157 participants), 36 participants (23%) met the SCT symptom level criterion and 50 participants (32%) met the impairment criterion. Nineteen participants (12%) met both criteria and were thus classified as having high SCT. Independent-samples t tests indicated that, after applying a Bonferonni correction for multiple comparisons (.05/7 = .007), high SCT participants had higher BAARS-IV inattention, BAARS-IV hyperactivity-impulsivity, CES-D depression, DASS-21 anxiety, DERS emotion dysregulation, and BFIS social impairment scores, as well as lower BASC Interpersonal Relations scores, than participants without elevated SCT (all ps ≤ .001).
was significantly associated with poorer social functioning as measured by both the BASC Interpersonal Relations and the BFIS Social Impairment variables, with the exception that anxious symptoms were not significantly correlated with the BASC Interpersonal Relations domain. Likewise, each of the psychopathology dimensions was significantly positively associated with difficulties in emotion regulation, ranging from a correlation of .27 for the correlation between ADHD-impulsivity and emotion dysregulation to .66 for the correlation between depressive symptoms and emotion dysregulation. SCT, ADHDinattention, and anxiety were also strongly associated with emotion dysregulation (rs = .55-.58, all ps = .001).
Correlation Analyses
Regression Analyses
For all study variables, the absolute values of skewness and kurtosis were below 2.0. Variable means, standard deviations, and intercorrelations are displayed in Table 1. Correlations were examined to determine which independent variables (i.e., SCT, ADHD-inattentive, ADHDhyperactivity, ADHD-impulsivity, anxiety, and depression) and demographic variables (i.e., sex, age, and race) were associated with the dependent variables of interest (i.e., social functioning, difficulties in emotion regulation) and thus retained for inclusion in the regression analyses. As displayed in Table 1, age was significantly negatively correlated with BASC Interpersonal Relations (r = −.20, p = .01) and so was included as a covariate in all subsequent models. In addition, each of the psychopathology dimensions (i.e., SCT, ADHD-inattention, ADHDhyperactivity, ADHD-impulsivity, anxiety, and depression)
Next, hierarchical regression analyses were conducted to examine whether SCT symptoms were associated with difficulties in social functioning and emotion regulation after controlling for ADHD, anxious, and depressive symptoms. Across all regression analyses, no variance inflation factor (VIF) values were above 3 (values >10 are typically considered problematic) and no tolerance values were below .30 (values
